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PREVIEW

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Chair Terry Rabinowitz, MD, FAPA, FAPM Associate Professor of Psychiatry & Family Medicine Director Telepsychiatry University of Vermont Fletcher Allen Health Care Burlington, VT Phone: 802-847-2112 Fax :802-847-3090 fax Email:terry.rabinowitz@vtmednet.org

Vice-Chair Lisa J. Roberts, PhD Business Manager, Health Innovations and Grants Viterion TeleHealthcare 10042 Main Street, Suite 401 Bellevue, WA 98004 Phone: 425-417-8209 Email:lisa.roberts@viterion.com

SIG Goals for 2006-2007 (word)

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Minutes from Telemental Health SIG Conference September 4, 2007 Minutes from Telemental Health SIG Conference February 7, 2007 Minutes from Telemental Health SIG Conference January 7, 2007 Minutes from Telemental Health SIG Conference November 1, 2006 Telemental Health SIG Forum Minutes (pdf) ATA 2004, Tampa, Florida, May 3, 2004 Telemental SIG Conference Call Summary (pdf) January 9, 2004 Telemental SIG Group Meeting Report June 4, 2002 Telemental SIG Group Meeting Report June 2, 2001

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2006 San Diego, CA The Role of Mental Health in Disaster Response - Lessons Learned from Hurricane Katrina Eugene F. Augusterfer, LCSW Global Mental Health Network, McLean, VA Riley Children's Hospital - Telemedicine Applications in Pediatric Mental Health Greg A. Beck1, MHA, David Dunn2, MD 1Riley Children's Hospital, Indianapolis, IN; 2Indiana University, Indianapolis, IN Evaluation From a Diagnostic Efficacy Trial of Child Telepsychiatry Eve-Lynn Nelson, Sharon Cain, Poonam Khanna, Ryan Spaulding Kansas University Medical Center, Kansas City, KS Regional Health Information Organizations (RHIO's) and Telemedicine - Lessons to Be Learned Peter M. Yellowlees, MBBS, MD UC Davis Medical Center, Sacramento, CA An Economic Evaluation of Telehealth SCID Interviews with American Indians Elizabeth Brooks, MS, Jay Shore, MD, MPH, Daniel Savin, MD, Spero Manson, PhD, Anne Libby, PhD University of Colorado Health Sciences Center, Aurora, CO The eMental Health Project at UC Davis - A Consultation Liaison Primary Care Program with Excellent Clinical Outcomes Peter M. Yellowlees, MBBS, MD, James Bourgeois, MD, Donald M. Hilty, MD,

Jonathan Neufeld, PhD, Hattie Cobb UC Davis Medical Center, Sacramento, CA If At First You Don't Succeed: Rebuilding a Telepsychiatry Program Andy D Kroeker1, BSc, MPA, Kim Timleck1, BSW, MHSc, CHE, Sharon Sanders2 1VideoCare, London, Ontario, Canada; 2Regional Mental Health Care, London, Ontario, Canada Using Technology to Increase Access to Evidence-Based Mental Health Services Lisa J. Roberts, PhD Viterion TeleHealthcare, LLC, Bellevue, WA Using Video Conferencing to Improve Best Practices Robert K. White , LCPC, David Pruitt, MD University of Maryland Psychiatry, Baltimore, MD Psychiatry Resident Training Program Utilization of Telepsychiatry Eve-Lynn Nelson, PhD, Barry Liskow, Ryan Spaulding Kansas University Medical Center, Kansas City, KS Symptom Relief in Veterans with PTSD via Telephone or Videophone Therapy Mary K. Roberts, PhD Department of Veterans Affairs Medical Center, Salt Lake City, UT Forensic Telepsychiatry in the U.S. Army Brett J. Schneider, MD Walter Reed Army Medical Center, Washington, DC Diagnostic Reliability of Telepsychiatry in American Indian Veterans Jay H. Shore, MD, MPH, Daniel Savin, MD, Heather Orton, MS, Jan Beals, PhD, Spero M. Manson, PhD American Indian and Alaska Native Programs, University of Colorado at Denver and Health Sciences Center, Aurora, CO Support Groups by Videoconferencing for Women with Breast Cancer Kate Collie, PhD,1 Mary Anne Kreshka, MA,2 Speranza Avram,3 Rebecca Parsons, LCSW4, Susan Ferrier, BSN,3 Kathy Graddy, Cheryl Koopman, PhD1 1Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA; 2Sierra College, Rocklin, CA; 3Northern Sierra Rural Health Network, Nevada City, CA; 4Sierra Nevada Cancer Center, Grass Valley, CA sh.com Jason Cafer MD, Iconic Health's HomePsych.com's communication platform for online telecounseling and telepsychiatry integrated with an electronic health record specialized for mental health Patient Satisfaction With Mental Health Telemedicine in Rural Arkansas Cathy A. Irwin, PhD, RN, Ann B. Bynum, EdD Rural Hospital Program, University of Arkansas for Medical Sciences Little Rock, AR Counseling Center Based Student Tele-Mental Health at a Rural University Ellen N.Emerson, PhD,1 Wendy L.Wolfe, PhD,1 Elena V.Khasanshina, MD, PhD,2 Stewart A.Shevitz, MD,2 David P Matthews, PhD,1 Peter F Buckley, MB, BCh, BAO,2 Max E Stachura, MD2 1Georgia Southern University, Statesboro, GA; 2Medical College of Georgia, Augusta, GA Mental Health Outcomes: A Comparison Study of Home-Based Telehealth Versus Traditional Home Health Services Pamela G. Forducey, PhD, ABPP,1 Victoria Phillips, DPhil,2 Teresa Tisdell, OTR/L, MPH,1 Andrew Heuser, PT,1 Stephen Dawson, PT,1 Dana DuRoy, OTR/L, MBA1 1INTEGRIS TeleHealth, Oklahoma City, OK; 2Emory University, Rollins School of Public Health, Atlanta, GA 2005 Denver, CO Pediatric Telemental Health: Reimbursement Katherine Flynn, RN, MS1, Dennis Wilbert, MC1, Kathleen Myers, MD, MPH1,2,

Stephen Sulzbacher, PhD1,2, Sanford Melzer MD, MBA1,2 1Children's Hospital & Regional Medical Center, Seattle, WA; 2University of Washington School of Medicine, Seattle, WA Pediatric Telemental Health: Juvenile Corrections Deborah Thurber, MD1,2, Kathleen Myers, MD, MPH1,2, Dennis Wilbert1, Eric Trupin, PhD1, Roxanne Morganthaler1, Katherine Flynn, RN, MS1, Sanford Melzer, MD, MBA1,2 1Children's Hospital & Regional Medical Center, Seattle, WA; 2University of Washington School of Medicine, Seattle, WA Pediatric Telemental Health: Outpatient Care Deborah Thurber, MD1,2, Kathleen Myers, MD, MPH1,2, Stephen Sulzbacher, PhD1,2, Dennis Wilbert1, Katherine Flynn RN, MS1, Sanford Melzer MD, MBA1,2, 1Children's Hospital & Regional Medical Center, Seattle, WA; 2University of Washington School of Medicine, Seattle, WA Telehealth Treatment of Depression-Translating Research Findings into Practice Eve-Lynn Nelson, PhD Center for TeleMedicine, Kansas University Medical Center, Kansas City, KS Telemental Health, Technology and Care Coordination: Initial Program Outcomes Anita S. Urdiales, RN, MSN, CNS1, Jeff Lowe, MSW, LCSW2 1VHA Eastern Colorado Health Care System, Denver, CO; 2VHA Rocky Mountain Network VISN9 1, Denver, CO Diagnosis and Treatment of Delirium in Elders From a Distance Terry Rabinowitz, MD, DDS1,2, Pamela L. Blume, RN3, Katharine M. Murphy, PhD, RN4, Michael Caputo, MS1,2, Michael Ricci, MD1,2 1University of Vermont College of Medicine, Burlington, VT; 2Fletcher Allen Health Care, Burlington, VT; 3Alice Hyde Nursing Home, Malone NY; 4Hebrew Rehabilitation Center for Aged, Boston, MA Technology Use in a Child Behavioral Health Clinic COL Ryo Sook Chun, MC, USA, Sona P. Patel, MPH, BS, MAJ(P) Robert Forsten, MC, USA, LTC Nancy Black, MC, USA Walter Reed Army Medical Center, Washington, DC Next Generation of the Tele-Behavioral Health System and Statistical Analysis Usage Grigoriy Gadiyak, PhD1, Valeriya Gadiyak, PhD1, COL Ryo S Chun, MC2, COL Ronald K Poropatich, MD1, Daisy DeWitt, MS1 1North Atlantic Regional Command, Telemedicine Directorate, Washington, DC; 2Walter Reed Army Medical Center, Washington, DC Co-location of Mental Health Services and Primary Care using Telemedicine Oscar Boultinghouse, MD, John Allen, MBA University of Texas Correctional Managed Care, Galveston, TX Child and Adolescent Psychiatric Consultations for American Indian Children Douglas K. Novins, MD1, Daniel Savin, MD, Mark Garry, MD1,2, Jay H. Shore, MD, MPH1, Spero M. Manson, PhD1 1American Indian and Alaska Native Programs-University of Colorado Health Sciences Center, Denver, CO; 2Sioux San Indian Health Service Hospital, Rapid City, SD Telemental Health Treatment for American Indian Veterans Jay H. Shore, MD, MPH, Spero M. Manson, PhD American Indian and Alaska Native Programs, University of Colorado Health Sciences Center, Denver, CO Store and Forward Based Telemedicine Platform for Treatment of Autism R. Oberleitner1, S. Pharkute, MS2, S. Laxminarayan, PhD2, J. Ball, EdD3, J. Harrington, MD4, R. Naseef, PhD5 1Princeton Autism Technology, Princeton, NJ; 2Idaho State University, Pocatello, ID; 3Autism Education Services, Youth Consultation Services/Sawtelle, Montclair,

NJ; 4Department of Pediatrics, New York Medical College, Valhalla, NY; 5Special Needs Families Resource Center, Philadelphia, PA Constraints on Effectiveness of Psychological Telemedicine in Older Adults Neil Charness Florida State University, Tallahassee, FL Electronic Behavioral Health Screening in a Military Environment COL Gregory A. Gahm, PhD, Barbara Lucenko, PhD Army Behavioral Health Technology Office, Tacoma, WA Parent's Perspective of Therapeutic Alliance: Video Teleconferencing versus Face-ToFace LTC Nancy B. Black, MD, Sona P. Patel, MPH, COL Stephen J. Cozza, MD Walter Reed Army Medical Center, Washington, DC 2004 Tampa, FL A Statewide Second Opinion Child Psychiatry Telemedicine Service Peter Yellowlees1, MD, BSc, MBBS, FRANZCP, MRC(Psych), MAPsS, MRACMA, FACHI, Andrew Hockey1, BA(Hons), Psych, Stephen Murphy2, MBBS, FRANZCP 1Centre for Online Health, The University of Queensland, Brisbane, Australia; 2Royal Children's Hospital, Brisbane, Australia Telepsychiatry: Improving Access in Rural Northern Idaho Sue Fox, MPH North Idaho Rural Health Consortium, Bonner General Hospital, Sandpoint, ID An Evaluation of Telepsychiatry from a Training Perspective Barry Liskow, MD, Eve-Lynn Nelson, PhD, Sharon Cain, MD, Poonam Khanna, DO, Paula Baum, RN Kansas University Medical Center, Kansas City, KS Minimum Data Set Facilitates Telepsychiatry Consultations for Nursing Home Residents Terry Rabinowitz1,2, MD, FAPM, Michael A. Ricci1,2, MD, Michael P. Caputo, Jr. 1, MS, Katharine M. Murphy3, PhD, RN 1University of Vermont College of Medicine, Burlington, VT; 2 Fletcher Allen Health Care, Burlington, VT; 3Hebrew Rehabilitation Center for Aged, Boston, MA Expansion of eHealth Services and Indian Health Care in California Barbara Johnston, MSN The California Telemedicine & eHealth Center (CTEC), Sacramento, CA Telepsychiatry: Where the Medium Supports the Process, a Case Study George Brandt, MD Walter Reed Army Medical Center, Washington, DC Using Automation to Screen for Depression in Primary Care Clinics LTC Paulette Williams, AN, MSN, DrPH, LTC Susan Emanual, MC, LTC Simon Pincus, MC Tripler Army Medical Center, Honolulu, HI Effectiveness of Telemedicine as a Mental Health Consultative Procedure Peggy Keilman, PhD, FPPR University of New Mexico, Albuquerque, NM Development of a Flexible Telemedicine Decision Analysis Tool Gregory L Thelen1,2, MD, Sandra K. Schmunk, BS, MT-ASCP, MA 1VA Midwest Health Care Network, Minneapolis, MN; 2Mental Health Service Line, University of Minnesota The Impact of Mental Health Telemedicine on Patients' Cost Savings Cathy A. Irwin, PhD, RN, CS, Ann B. Bynum, EdD, Joseph A. Banken, MA, PhD, HSPP University of Arkansas for Medical Sciences, Little Rock, AR An Expert System for Behavioral Health Risk Assessment Gregory Gahm, PhD, Tracy L. Hartford

Army Behavioral Health Technology Office, Madigan Army Medical Center, Tacoma, WA Telepsychiatry Research Project in Michigan: Outcomes and Impacts Pamela Whitten, PhD Michigan State University, East Lansing, MI Telepsychiatry and Research: Lessons Learned LTC Nancy B. Black, MD, COL Stephen J. Cozza, MD, Sona P. Patel, MPH Walter Reed Army Medical Center, Washington, DC Florida Initiative in Telemedicine and Education Improves Health Status of Children with Diabetes Toree Malasanos1, MD, Muir2, A., Dubault3, R., Molinari3, S., Geffken1, G., Burlingame1, J., Greco1, J., Hruska1, E., Watson4, D., Ketterson1, T., Glueckauf1, R., Patel1, B., Klein1, J., Sloyer4, P. 1University of Florida, Gainesville, FL; 2Medical College of Georgia, Augusta, GA; 3Florida Center for Medicaid Issues, University of Florida, Gainesville, FL; 4Department of Health, Children's Medical Services, Gainesville, FL 2003 Orlando, FL Best Practices: Ethics and Professionalism in the Provision of Telemedicine Tracy Gunter, MD Department of Neuropsychiatry, University of South Carolina School of Medicine, Columbia, SC A Randomized Trial Delivering Psychotherapy via Telemedicine James E. Mitchell, MD1,2, Stephen Wonderlich, PhD1,2, Ross Crosby, PhD1,2, Tricia Myers, PhD1,2, Lorraine Swan-Kremeier, PsyD1,2, Kathy Lancaster1 1Neuropsychiatric Research Institute, Fargo, ND; 2Department of Neuroscience University of North Dakota School of Medicine and Health Sciences, Fargo, ND Development of an Electronic Behavioral Health Record Mitra Rocca, MSc1, John Pajak, BS1, Gregory Gahm, PhD2, Jessica Oehlrich, BS2 1United States Army Medical Research & Materiel Command (USAMRMC), Telemedicine and Advanced Technology Research Center (TATRC), Fort Detrick, MD; 2Madigan Army Medical Center, Tacoma, WA Web-based Automated Mental Health Intake System (WAMHIS): Examining Parent and Provider Satisfaction COL Ryo Sook Chun, MD1, Donna Edison, DO1, MAJ Anthony Cox, MS2, LTC(P) Stephen Cozza, MD1, Grigorii Gadiyak, PhD1, Valeriya Gadiyak, PhD1, William Parker, MS1, Scott Mann, JD1, COL Ronald Poropatich, MD1, Daisy DeWitt1, Sarah Rosquist, BS1 1Walter Reed Army Medical Center, Washington, DC; 2US Army Center for Health Promotion & Preventive Medicine, Washington, DC Telemedicine for Pediatric Mental Health in Rural Areas Kathleen Myers, MD, MPH1,2, Stephen Sulzbacher, PhD1,2, Sandor Melzer, MD, MBA2,3 1University of Washington, Seattle, WA; 2Chidren's Hospital & Regional Medical Center, Seattle, WA; 3Children's Health Access Regional Telemedicine (CHART) Program, Seattle, WA Telepsychiatry in a Rural Women's Shelter: Addressing Domestic Violence Christopher R. Thomas, MD University of Texas Medical Branch, Galveston, TX

Considerations in Treating Severe Mental Health Conditions via Telemedicine John Kennedy, MD National Naval Medical Center, Bethesda, MD Telepsychiatry Consultation to School Tracy D. Gunter, MD1, Christopher R. Thomas, MD2, R. Andrew Harper, MD3 1University of South Carolina School of Medicine, Columbia, SC; 2University of Texas Medical Branch, Galveston, TX; 3University of Texas Medical School at Houston, Houston, TX Telepsychiatry in the Forensic Setting Tracy D. Gunter, MD University of South Carolina and the South Carolina Department of Mental Health, Columbia, SC Emergency Telemental Health - Canada's First Krisan Palmer, RN1, Rose Montgomery, BN1, Annette Harland2 1Atlantic Health Sciences Corporation, Saint John, New Brunswick, Canada; 2 Community Mental Health Services, St.Stephen, New Brunswick, Canada Telepsychopharmacology: An Application in Telepsychiatry Norman Alessi, MD University of Michigan Medical School, Ann Arbor, MI Telepsychiatry Service Versus Face-to-Face Psychiatry Service - A Preliminary Outcome Study COL Swarnalatha Prasanna, MD Telepsychiatry & Community Mental Health, Walter Reed Army Medical Center, Washington, DC Development of a Web-Based Behavioral Health Record System Grigoriy Gadiyak, PhD, Valeriya Gadiyak, PhD, William Parker, MS, COL Ronald K. Poropatich, MD, COL Ryo S. Chun, MC, COL Swarnalatha Prasanna, MD, MAJ Anthony Cox, MS, LTC Steve Cozza, MC, Donna Edison, DO, Sarah Rosquist Walter Reed Army Medical Center, Washington, DC 2002 Los Angeles Internet Enabled Neuropsychological Assessment MAJ Mark R. Baggett, PhD1, Mark P. Kelly, PhD1, CPT Daniel K. Christensen, PhD1, LTC Gregory A. Gahm, PhD2, Robert L. Kane, PhD3,4, CPT John D. Via, PhD5, CPT Victoria M. Ingram, PsyD1, Linda Whitby, MD1, Zhengi Y. Sun1, Daisy T. Dewitt1, Lisa M. Korenman, MA1, 1Walter Reed Army Medical Center, Washington, DC; 2Madigan Army Medical Center, Tacoma, WA; 3VA Maryland Heath Care System, College Park, MD; 4University of Maryland, College Park, MD; 5Fort Sam, Houston, TX Student Mental Health Outreach Using Online Support Iverson C. Bell, Jr., MD Morehouse College, Morehouse School for Medicine, Atlanta, GA Virtual Reality In Healthcare Peter M. Yellowlees, MD, BSc, MB, BS, FRANZCP, MRC, MAPsS, MRACM Centre for Online Health, The University of Queensland, Brisbane, Australia A Comparison Of Innovation Adopters And Non-Adopters Within A Telemedicine Initiative: An Evaluation Of Innovation Attributes To Explain Telemedicine Diffusion David J. Cook, PhD, Gary C. Doolittle, MD, Ashley Spaulding, Debbi Swirczynski

Center for Telemedicine & Telehealth, University of Kansas Medical Center, Kansas City, KS Adolescent Telepsychiatry Norman E. Alessi, MD, Gary Wautier, PhD University of Michigan Healthcare System, Ann Arbor, MI Access And Outcomes Through The Michigan Telepsychiatry Project Pamela Whitten, PhD1, Zora Ziazi, MA1, Linda Marion, MD2 1Michigan State University, East Lansing, MI; 2Lifeways, Jackson, MI Linkages For Increasing Access To Psychiatric Care In Rural MUA Glenda Walker, RN, DSN1, Ben G. Raimer, MD2, Jeanette Hartshorn, PhD, RN, FAAN2, Nancy Speck, PhD2, Rowdy Stovall2 1Stephen F. Austin State University, Nacagdoches, TX; 2University of Texas Medical Branch, Galveston, TX Web-Based Automated Mental Health Intake System (WAMHIS) COL Ryo S. Chun, MD, LTC Steve Cozza, MD, Donna L. Edison, DO Walter Reed Army Medical Center, Washington, DC Behviorial Health Window Of Opportunity Holly E. Russo, RN, MS1, Marlene Maheau, PhD2, Harvey Komet, MD3 1Telemedcine Solutions/Telehealth Works, Juno Beach, FL; 2Alliant University & Selfhelpmagazine.com, San Diego, CA; 3Cyber-Care, Boynton Beach, FL Behavioral Telehealth For Pain Management: Efficacy And Consumer Satisfaction Philip R. Appel, PhD, Joseph Bleiberg, PhD, John Noiseux, MS National Rehabilitation Hospital, Washington, DC 2001 Ft. Lauderdale The Capacity to Adapt, Turning Connections Into Relationships via Video Teleconferencing (55.0KB) LCDR Brian J. Grady, MD National Naval Medical Center, Bethesda, MD

If you are interested in participating in the Telemental Health Special Interest Group simply contact the chair of the SIG or email ATA at membership@americantelemed.org or call ATA at 202.223.3333.

The effectiveness of telepsychiatry: https://www.cpa-apc.org/Publications/Archives/Bulletin/2003/october/hilty.asp Donald M. Hilty, MD Associate Professor of Clinical Psychology, University of California, Davis, Sacramento, California. Weiling Liu, BS, Shayna Marks, BS Postgraduate Researcher, University of California, Davis, Sacremento, California. Edward J. Callahan, PhD Professor of Family and Community Medicine, University of California, Davis, Sacramento, California.

Abstract: Effectiveness must be determined for each new technology because it may have advantages and disadvantages over what is currently offered. We reviewed the literature to

synthesize information on whether telepsychiatry is effective. Based on the literature, we suggest that the effectiveness of telepsychiatry be evaluated on access to care, quality of care (that is, outcomes, reliability, satisfaction and comparison with in-person care), costs and empowerment. Further, we discuss other factors that influence effectiveness (for example, technology, administrative coordination and financial support). Telepsychiatry appears effective, and recommendations are offered for further evaluation of its effectiveness. Key Words: telepsychiatry, effectiveness, rural, mental health, review Telepsychiatry, in the form of videoconferencing, has been well received in terms of increasing access to care and user satisfaction (14). Questions persist, however, about its effectiveness; there are few clinical outcome studies, cost data and randomized trials. There may also be a positive reporting bias in the literature. Effectiveness, from the Latin origin of the word, is defined as having the power to produce an effect . . . a decisive effect; efficient; as . . . an effective . . . remedy (5). Ideally, effectiveness should be considered for the patient, provider, program, community and society. In telemedicine and telepsychiatry, authors have rarely discussed the idea of effectiveness (6,7). However, they have discussed the subject indirectly with respect to quality of care, clinical outcomes and costs (8). Frameworks proposed for telepsychiatry assessment have information that applies to the concept of effectiveness, including what technology is used (911), how tele- psychiatry is integrated with other services (9,11), what it costs (6,7,911), how it compares with previous services and its quality (for example, whether it enhances diagnosis and whether it compares favourably with in-person care) (911). This article discusses telepsychiatrys effectiveness for clinicians, clinical educators and clinical researchers. It focuses individually on the parameters of access, quality of care (that is, outcomes, reliability and comparison with in-person care), satisfaction, costs, education and empowerment. It is obvious that the parameters affect the assessment of one another (6). We offer recommendations for further evaluation. Methods We conducted a comprehensive review of the telepsychiatry literature from 1965 to June 2003, using Medline, PubMed, PsycINFO, Embase, Science Citation Index, Social Sciences Citation Index and Telemedicine Information Exchange databases. The Journal of Telehealth and Telecare was also hand searched for the years during which it was not included on Medline. Key words included telepsychiatry, telemedicine, video- conferencing, effectiveness, efficacy, access, outcomes, satisfaction, quality of care and costs. The first author reviewed article titles and abstracts to decide whether they applied to the theme of effectiveness. Selected articles were pulled, and references were reviewed for potential additional articles. The data were categorized, based on the key words used for the initial search. In addition, we used a standard qualitative method based on grounded theory analysis to explore the prevalent trends in the literature to identify additional key, recurrent themes (12). Ideas were recorded by analytic memos and were identified as highly recurrent (that is, reaching theoretical saturation) according to a coding scheme that organized them into meaningful categories (12). Education and empowerment were identified as categories. Measures of Effectiveness Access to Care Access to care is determined by geographic, economic, cultural and (or) social barriers to needed care. Access to psychiatric care has increased to rural (13,14), suburban (15) and

urban areas (16). Telepsychiatry links academic health centres with health-care professionals in shortage areas (17). Points of service are theoretically limitless. A full range of evaluation (general, forensic and neuro- psychological), consultation, treatment (medication and therapy) and case management services have been provided (2). Telepsychiatry programs worldwide have been described in surveys (18,19) and in telepsychiatry research reviews (1,18,19). Quality of Care Outcomes. There is a small but growing literature with respect to telepsychiatry inerventions (Table 1). Most patients are referred for diagnostic evaluation and (or) treatment recommendations, with the view that two opinions are better than one (6,20,21). Indeed, in a study of specialty consultation including telepsychiatry, specialists changed the diagnosis and medications in 91 per cent and 57 per cent of cases, respectively; primary care interventions led to clinical improvements in 56 per cent of cases (22). Similarly, nurse telecare improved patient depression, mental health functioning and satisfaction (23). Quality of care may also be defined as avoiding unnecessary evaluations, procedures and transfers in emergencies (24), as reducing waiting times (25) and as more appropriately using psychiatric intensive care units (26). Cognitive-behavioural therapy for children with depression was as successful at 128 kilobytes (KBS) per second by telepsychiatry as inperson care (27). No difference was found between Global Assessment of Function over 6 months by telepsychiatry at 128 KBS and a control group (28). Similarly, no improvement occurred over the course of 12 months in another study (29). Table 1 Quality of care: summary of outcome and cost studiesStudy Outcome Doze and others (20) 90 Adult outpatients 128384/NS Canada Specialists assisted with diagnosis and treatment; no outcomes measured Graham (75) Haslam and McLaren(26) Hunkeler and others (23) 39 2 302 Adult outpatients Adult and geriatric outpatients Adult outpatients in primary care NS U.S. 768/NS 128/NS U.S. U.S. Reduction in hospitalizations More appropriate use of inpatient services Nurse telecare improves depressive symptoms, functioning and satisfaction vs. usual care Johnston and Jones (76) 40 Nursing facility residents 128/adjusted to 5-inch square Kennedy and Yellowlees (29) Lyketsos and others (58) Nelson and others (27) Nesbitt and others (22) 32 NAP 28 164 Adult patients Geriatric dementia patients Childhood depression Adult patients with specialist consultations including psychiatry Zaylor (28) 49 Adult outpatients with depression or schizoaffective disorder Cost Alessi and others (53) Doze and others (20) NAV 90 Adult forensic inpatients Adults NAV/NAV 336384/NS U.S. Alberta Telepsychiatry is cost-effective Costs break even at 7.6 consultations 128/NS U.S. 128/NS 128384/30 U.S. U.S. 128/NS NS/20 U.S. U.S. U.S. Elimination of travel and more contact between patients and staff No improvement Reduction in psychiatric hospitalization Substantial clinical change, equivalent to in-person care Change in diagnosis in 91% of cases and clinical improvement in 56% of cases No difference in GAF scores at 6-month follow-up vs. in-person n Patients KBS/frames Location Comment(s)

Hailey and others (9) Mielonen and others (55)

NAP 14

Adults Adult inpatients

NAP/NAP NS

U.S. Finland

Reduced costs to rural patients Savings in health-care costs, reduction in travel and ease and speed of consultation

Simpson and others (38)

379

Adult outpatients

128384

Canada

Costs break even at 224 consultations/year; less if also used for administration

Trott and Blignault (54)

50

Adult and child outpatients

NS

Australia Substantial savings in health care costs from reduction in travelling and patient transfers

KBS = kilobytes per second; NAV = not available; NAP = not applicable; NS = not specified.

Reliability. Studies on the reliability of telepsychiatry have been conductedalmost all with good results generally at transmission speeds of 128 KBS to 384 KBS (1,2). Diagnoses have been made reliably, with good interrater reliability, for a wide range of psychiatric disorders for children, adults and geriatric patients. Limitations have included patients difficulties in hearing and decreased attention (30). Comparison with In-person Care. Telemedicines ability to simulate real-time experiences in terms of audio and video quality is important. Terrestrial transmission at 128 KBS provides a good picture with a 0.3-second signal delay, but words are cancelled out if spoken simultaneously. Satellite transmission involves a delay of 0.5 to 1.0 second, as seen on worldwide broadcasts. Low KBS (that is, 56 KBS plus or minus 128 KBS) and satellite use may interfere with the building of rapport, detection of nonverbal cues (31) and depersonalized content (32), a task-oriented focus and a turn-taking conversation (33). No problems, however, were found with development of rapport in a small cohort comparing signal delays of 0, 0.3 and 1.0 second (34). Transmission at 384 KBS to 768 KBS has littleto-no delay. A review of randomized controlled trials, comparing telemedicine (not telepsychiatry) with in-person care showed no detrimental effects in outcomes and satisfaction (35). Patient and Provider Satisfaction A systematic review of the satisfaction literature in tele- medicine (not telepsychiatry) revealed limitations that included small sample sizes, informal evaluations and a lack of randomized trials (36). Table 2 summarizes tele- psychiatry satisfaction. Patients have expected a less satisfactory interaction than in a traditional physicianpatient encounter (37), but overall satisfaction has been very high (2,36). Interestingly, high satisfaction has been reported despite equipment problems (38). Thus far, reduced time to travel (8,20,39), less absence from work (20), reduced waiting time (25,36) and more patient choice and control (20) have been reported. Other potential predictors are frames per second (FPS) (for example, 30 FPS is television quality) (40), demographic factors (for example, age, sex or ethnicity) (41), state- and trait-dependent factors (for example, acute depression vs. depression in remission) (41), cost, satisfaction with and availability of local services (42), and provider qualities (43). Table 2 Summary of telepsychiatry key satisfaction studiesStudy Baer and others (77) n 26 Patients Patients with obsessivecompulisve disorder Baigent and others (78) 63 Adult state hospital inpatients 128/NS Australia Many patients were satisfied and preferred it instead of inperson Ball and McLaren (30) 6 Adult inpatients Low-cost system/NS U.K. Also measured satisfaction with in-person, telephone, and hands-free telephone KBS/frames 128/NS Location U.S. Comments Average to better than inperson care

Blackmon and others (45) Bratton and Cody (48)

43 20

Child outpatients Geriatric patients in a retirement community

NS/NS 128/NS

U.S. U.S.

Parent satisfaction was also very good Satisfied despite hearing and poor image problems

Callahan and others (44) Chae and others (79) Clarke (80)

93 30 32

Adult primary care outpatients Adult outpatients

128/15 33/NS

U.S. Korea Australia

Satisfaction equal to a nonpsychiatric population Equal to usual, in-person care Nurse satisfaction was greater than physician satisfaction

Nurses and providers in rural 128/NS clinics

Dongier and others (46) Doze and others (20)

50 90

Adult, child outpatients Adult outpatients

Closed circuit TV/NS 128384/NS

Canada Canada

Equal to usual, in-person care Positive because of less travel and less absence from work; negative perceptions

Elford and others (32)

23

Children

336/NS

U.S.

Diagnosis and treatment recommendations equal to usual, in-person care

Graham (75)

39

Adult outpatients

768/NS

U.S.

Positive patient acceptance of telepsychiatry aftercare (90% positive ratings)

Hilty and others (41)

40

Adult primary care outpatients

384/15

U.S.

Satisfaction equal for inperson and telepsychiatric care, if patient given the choice

Johnston and Jones (76)

40

Nursing facility residents

128/NS

U.S.

Patients and families expressed appreciation for the service

McCloskey (39) Mielonen and others (55)

236 14

Adult outpatients Adult inpatients

128/NS NS/NS

U.S. Finland

Rural Montana; would have had to travel significantly High patient satisfaction (80% considered it to have been useful)

Ruskin (81) Simpson and others (25) Simpson and others (38)

NAV 230

Geriatric outpatients Adult outpatients Adult outpatients

NAV 384 384

U.S. Canada Canada

Geriatric satisfaction similar to adult satisfaction High level of satisfaction with the service and equipment High level of satisfaction with the service and equipment despite equipment problems in 17% of cases

Trott and Blignault (54)

50

Adult and child outpatients

NS/NS

Australia

High level of acceptance by patients and mental health professionals

Dongier and others (46)

NS

Primary care providers and psychiatrists

Closed circuit

Canada

Lower satisfaction in terms of ease, ability to express oneself, and quality of the relationship

Hilty and others (49)

NS; 200 Primary care providers pts

128384/30

U.S.

High satisfaction (for example, 4.5 on 5-point

scale) on all parameters; improved over time with increased use Elford and others (32) McCloskey (39) 2 1 Child psychiatrists Adult psychiatrist 336/NS 128 KBS U.S. U.S. High satisfaction except for rare technical problems High satisfaction (for example, 6.6 on 8-point scale) Hilty and others (21) 3 Adult psychiatrists 128384/30 U.S. High satisfaction (for example, 6.8 on 8-point scale) Doze and others (20) NS Adult psychiatrists 128384/NS Canada Generally pleased to evaluate patients before condition became more severe; efficient

Several interesting themes have emerged from the literature. First, most patients speak freely when using tele-psychiatry, will use it again, and rate their experiences with providers as positive. Satisfaction with telepsychiatry is similar to other specialty care provided via telemedicine (44). For evaluation and follow-up care, satisfaction with telepsychiatry care equalled that for in-person consultation (41). Patients of all ages have reported high satisfaction (32,45,46), even those with occasional trouble hearing or discomfort using the equipment (47,48). Consultee and psychiatrist satisfaction has been less consistently positive. Consultee (that is, nurse and psychologist) satisfaction with telepsychiatry was lower than for in-person consultation with respect to ease with the process, ability to express oneself and quality of the interpersonal relationship (46). Satisfaction, however, with another consultation-liaison service was high (that is, over 4.5 on a scale of 1 [poor] to 5 [excellent]) and increased after 2 or more consultations over a 1-year period. Rural primary care providers had significantly higher satisfaction than did suburban or urban providers (49). Although problems were rare, child psychiatrists indicated that technical problems (for example, unclear picture and video freeze) affected their ability to assess patients (32). One study raised concerns about the ease of the process, the ability to express oneself and the quality of the interpersonal relationship (46). Two other studies rated overall satisfaction with telepsychiatry highly (for example, 6.6 on a scale of 8) (21,39). Cost Studies This article reports cost studies briefly, because little information has been collected in a standard, prospective fashion (9). Ideally, both direct and indirect costs should be considered for patients, clinics, providers and society at large. Direct costs include equipment, installation of lines and other supplies. Fixed costs also include the rental of lines, as well as salary and wages and administrative expenses. Variable costs include data transmission costs, fees for service, and maintenance and upgrades of equipment. Studies have reported cost data (Table 1), and recommendations have been made to improve evaluation. A meta-analysis of cost data found that only 38 of 551 articles contained any quantifiable data, leading to a conclusion that it was premature to assume that telemedicine is cost-effective (50). Telepsychiatry is cheaper than travel for patients (8,25,51,52). With respect to programs, tele- psychiatry service has been shown to be cheaper (14,5255), equivalent (9) and more expensive than outreach in-person services (42,48,56,57). When expensive transfers are involved, it may be cost-effective (26,5355,58). Break-even analyses demonstrated that a telepsychiatry service needs approximately seven consultations weekly (20,38,51). Guidelines offer suggestions to improve data that are related to costs (9,10,5962), mainly through cost-effectiveness and costbenefit analysis (63,64).

Education Telemedicine has been used for several educational initiatives, including provider education (65,66), clinical consultation (15) and supervision (67). It has successfully linked academic centres with rural areas for continuing medical education in North America and internationally (17,65). Clinical consultations also reduce provider isolation, provide casebased learning (68,69) and help with decision support (70), particularly when providers sit in for the evaluation (71). Outcomes of interventions by telepsychiatry have been assessed in only one study (22). Empowerment Patients have reduced travelling time (8,20,39), less time absent from work (20), reduced waiting time (25) and more choice and control (20). Primary care providers have access to specialists for patient care and education, are able to keep treating their patients, rather than referring (49), and feel good about their practice. Communities have kept their patients, reduced costs for transfers (54,55) and retained dollars that would otherwise have been lost to suburban centres upon referral (72). Communities presumably also benefit from providing a higher quality of care, from having more opportunities for staff education, from experiencing greater ease with recruitment and from having greater ease with accreditation. Other Factors Affecting Effectiveness Technology. The most important issue is having adequate bandwidth for the task at hand and alternative plans if a limitation exists. The transmission speed in KBS and picture quality in FPS are important determinants of the interaction quality between the provider and the patient (2,73). Administrative Coordination. Coordination is necessary to initiate and maintain a telepsychiatry program, particularly for clinical protocols, staffing time and technical assistance. Financial support is necessary from within the institution or from local, regional or federal agencies. Recommendations and Conclusions Telepsychiatry appears effective, based on the preliminary data on access to care, quality of care (that is, outcomes, diagnosis and ability for users to communicate), satisfaction and education. It also empowers patients, providers and communities. It is premature to claim that telepsychiatry is cost-effective (21). Technology and program coordination are important determinants to its short- and long-term viability. The results of this article appear similar to a review of 66 studies that compared telemedicine with a comparison group with respect to administrative changes, patient outcomes and economic issues (8). Thirty-seven (56 per cent) suggested that telemedicine had advantages over the alternative approach; 24 (36 per cent) found negative issues or were unable to draw conclusions, and five (eight per cent) found alternatives to be superior. Further assessment of telepsychiatrys effectiveness is needed (1,2,6,8,35,51,52). However, frameworks have been proposed (6,7,911), and Table 3 summarizes key aspects according to the parameters discussed in this article with regard to effectiveness. All parameters could benefit from further assessment, particularly in terms of outcomes and costs. RCTs with telemedicine are feasible, enable recruitment of patients and maintain enrolment (74). It is desirable to include a costeffectiveness or costbenefit analysis. Table 3 Recommendations for evaluating the effectiveness of telepsychiatryAccess Assessment of whether or not there was increased access to care and a description of the kind of care Services specific to the need (for example, consultation-liaison to primary care) Quality of Care Study methods Studies: randomized controlled trials with prospective data collection

Longitudinal data collection, as applicable and feasible Comparison group and (or) baseline data Systematic collection of surveys and other data Large sample size Reliabililty Outcomes Diagnostic ability Detection of limitations, if any Diagnostic quality Changes in clinical health status Changes in disease management Effect on patient quality of life Satisfaction Systematic collection of patient (lack of travel and lost work time), provider (assistance or education for decision-making) and specialist (potential lack of travel) satisfaction related to service: baseline, longitudinal, compared with alternative service options Costs Complete analysis with inclusion of all key components and broad focus: patient costs (lack of travel and lost work time), provider costs (application of skills to other patients), specialist costs (potential lack of travel, increased orders for tests), initial program investment costs (increased treatment costs), operational costs (including staff time) and societal costs Realistic estimates of costs Presence of a cost analysis, preferably cost-effectiveness or costbenefit analysis: short-term (period of study or project) and longterm (estimated, if not literally collected) Education Interventions: didactics, case-based teaching and (or) others Change in knowledge and (or) skill set at time of intervention; whether or not the change, if any, is preserved on follow-up Change in patient outcomes Empowerment Patients: reduced time to travel, less absence from work, reduced waiting time and more choice and control Primary care providers: access to specialists, education and able to keep their patients Community: able to keep their patients, higher quality of care, more opportunities for staff education, greater ease with recruitment and greater ease with accreditation Miscellaneous Technology Administration Other Adequate description of equipment, bandwidth, frames per second, and other parameters used Data on failures, problems (for example, reliability) Coordination to initiate and maintain a program at each site and between sites Financial support from institutional, local, regional, or federal grant agencies Reporting of positive and negative findings in the literature Acknowledgement of need to publish positive findings and other potential biases Sensitivity analysis to fit findings of one study or program to others

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Tele-Mental Health:File Format: PDF/Adobe Acrobat - View as HTML it deals with, as the title suggests, telepsychiatry in a rural setting. ... went on to report that rural telepsychiatry is ideally suited to provide ...

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Mental Health Care for the Rural Elderly: A BibliographyJanuary, 2005 The following references are from an article in the Telehealth Practice Report by Terry Rabinowitz, M.D., F.A.P.A., F.A.P.M. and Katharine M. Murphy, Ph.D., R.N. Dr Rabinowitz is at the Departments of Psychiatry and Family Medicine, University of Vermont College of Medicine and Fletcher Allen Health Care, Burlington, Vermont; Dr. Murphy is at Hebrew SeniorLife, Boston, Massachusetts. The article was entitled A Review of Telepsychiatry Services for Rural Elders: It's Time... We Think!(Vol 9 #6 12-13 2005) The following is an extensive list of references on mental health care for the rural elderly, including telehealth and face-to-face care. They are numbered sequentially as they appear in the article text. 1. Kumar V, Acanfora M, Hennessy CH, Kalache A. Health status of the rural elderly. J Rural Health 2001;17(4):328-31 2. Lau SC, Lee LL, Lin BJ, Liu YH, Yu SM, Tang SH, Sheng PC. The health status of rural and urban ambulatory elderly in Taipei County. Chang Gung Med J 2001;24(8):492-501 3. Coburn AF, Keith RG, Bolda EJ. The impact of rural residence on multiple hospitalizations in nursing facility residents. Gerontologist 2002;42(5):661-6 4. Neese JB, Abraham IL, Buckwalter KC: Utilization of mental health services among rural elderly. Archives of Psychiatric Nursing 1999;13(1):30-40 5. Lambert D, Agger MS. Access of rural AFDC Medicaid beneficiaries to mental health services. Health Care Financing Review 1995;17(1):133-45 6. Mueller KJ, Patil K, Ullrich F. Lengthening spells of uninsurance and their consequences. J Rural Health 1997;13(1):29-37 7. Eberhardt MS, Ingram DD, Makuc DM. Urban and rural health chartbook: Health United States 2001. Hyattsville, MD, National Center for Health Statistics, 2001 8. Goldsmith SK, Pellmar TC, Kleinman AM, Bunney WE (eds). Reducing suicide: a national imperative. Washington, DC, National Academy Press, 2002 9. Wagenfeld MO, Murray JD, Mohatt DF, DeBruyn JC (eds). Mental health and rural America: 1980-1993: an overview and annotated bibliography. Washington, DC, U. S. Government Printing Office, 1994 10. Strahan G. An overview of nursing homes and their current residents: data from the 1995 National Nursing Home Survey. Advance data from vital and health statistics; no. 280. Hyattsville, Maryland, National Center for Health Statistics, Public Health Service, 1997, pp 3 11. Zimmer JG, Watson N, Treat A. Behavioral problems among patients in skilled nursing facilities. Am J Public Health 1984; 74(10):1118-21 12. Rovner BW, Kafonek S, Filipp L, Lucas MJ, Folstein MF. Prevalence of mental illness in a community nursing home. Am J Psychiatry 1986; 143(11):1446-9 13. Borson S, Liptzin B, Nininger J, Rabins P. Psychiatry and the nursing home. Am J Psychiatry 1987; 144(11):1412-8 14. New Freedom Commission on Mental Health, Subcommittee on rural issues: background paper. Rockville, MD, DHHS, 2004; see p. 9 15. New Freedom Commission on Mental Health: Achieving the Promise: Transforming Mental Health Care in America, DHHS Pub. No. SMA-03-3832 (web site accessed Oct 15, 2004). Rockville, MD: 2003 16. The American Geriatrics Society and American Association for Geriatric Psychiatry recommendations for policies in support of quality mental health care in U.S. nursing homes. J Am Geriatr Soc 2003;51(9):1299-304 17. Katz IR, Lesher E, Kleban M, Jethanandani V, Parmelee P. Clinical features of depression in the nursing home. International Psychogeriatrics 1989; 1(1):5-15 18. Parmelee PA, Katz IR, Lawton MP. Depression among institutionalized aged: assessment and prevalence estimation. Journals of Gerontology 1989; 44(1):M22-9

19. Rovner BW, German PS, Brant LJ, Clark R, Burton L, Folstein MF. Depression and mortality in nursing homes. Journal of the American Medical Association 1991; 265(8):993-6 20. Richardson J, Bedard M, Weaver B. Changes in physical functioning in institutionalized older adults. Disabil Rehabil 2001; 23(15):683-9 21. Heeren O, Borin L, Raskin A, Gruber-Baldini AL, Menon AS, Kaup B, Loreck D, Ruskin PE, Zimmerman S, Magaziner J. Association of depression with agitation in elderly nursing home residents. J Geriatr Psychiatry Neurol 2003;16(1):4-7 22. Lebowitz BD, Pearson JL, Schneider LS, Reynolds CF, 3rd, Alexopoulos GS, Bruce ML, Conwell Y, Katz IR, Meyers BS, Morrison MF, Mossey J, Niederehe G, Parmelee P. Diagnosis and treatment of depression in late life. Consensus statement update. Jama 1997;278(14):1186-90 23. Revicki DA, Simon GE, Chan K, Katon W, Heiligenstein J. Depression, health-related quality of life, and medical cost outcomes of receiving recommended levels of antidepressant treatment. J Fam Pract 1998; 47(6):446-52 24. Covinsky KE, Fortinsky RH, Palmer RM, Kresevic DM, Landefeld CS. Relation between symptoms of depression and health status outcomes in acutely ill hospitalized older persons. Ann Intern Med 1997;126(6):417-25 25. Koenig HG, Kuchibhatla M. Use of health services by medically ill depressed elderly patients after hospital discharge. American Journal of Geriatric Psychiatry 1999;7(1):48-56 26. Parmelee PA, Katz IR, Lawton MP. Depression and mortality among institutionalized aged. Journal of Gerontology 1992;47(1):P3-10 27. Rovner BW. Depression and increased risk of mortality in the nursing home patient. American Journal of Medicine 1993;94(5A):19S-22S 28. Osgood NJ. Environmental factors in suicide in long-term care facilities. Suicide Life Threat Behav 1992;22(1):98-106 29. Alexopoulos GS, Bruce ML, Hull J, Sirey JA, Kakuma T. Clinical determinants of suicidal ideation and behavior in geriatric depression. Archives of General Psychiatry 1999; 56(11):1048-53 30. Streim JE, Oslin DW, Katz IR, Smith BD, DiFilippo S, Cooper TB, Ten Have T. Drug treatment of depression in frail elderly nursing home residents. American Journal of Geriatric Psychiatry 2000;8(2):150-9 31. Magai C, Kennedy G, Cohen CI, Gomberg D. A controlled clinical trial of sertraline in the treatment of depression in nursing home patients with late-stage Alzheimer's disease. American Journal of Geriatric Psychiatry 2000;8(1):66-74 32. McCurren C, Dowe D, Rattle D, Looney S. Depression among nursing home elders: testing an intervention strategy. Applied Nursing Research 1999;12(4):185-95 33. Fitzsimmons S. Easy rider wheelchair biking. A nursing-recreation therapy clinical trial for the treatment of depression. J Gerontol Nurs 2001;27(5):14-23 34. Rosen J, Rogers JC, Marin RS, Mulsant BH, Shahar A, Reynolds CF, 3rd. Controlrelevant intervention in the treatment of minor and major depression in a long-term care facility. American Journal of Geriatric Psychiatry 1997 5(3):247-57 35. Zerhusen JD, Boyle K, Wilson W. Out of the darkness: group cognitive therapy for depressed elderly. J Psychosoc Nurs Ment Health Serv 1991;29(9):16-21 36. Santmyer KS, Roca RP. Geropsychiatry in long-term care: a nurse-centered approach. J Am Geriatr Soc 1991;39(2):156-9 37. Llewellyn-Jones RH, Baikie KA, Smithers H, Cohen J, Snowdon J, Tennant CC. Multifaceted shared care intervention for late life depression in residential care: randomised controlled trial. Bmj 1999;319(7211):676-82 38. Tyrrell J, Couturier P, Montani C, Franco A. Teleconsultation in psychology: the use of videolinks for interviewing and assessing elderly patients. Age Ageing 2001;30(3):191-5

39. Johnston D, Jones BN, 3rd Telepsychiatry consultations to a rural nursing facility: a 2-year experience. J Geriatr Psychiatry Neurol 2001;14(2):72-5 40. Sumner CR. Telepsychiatry: challenges in rural aging. J Rural Health 2001;17(4):370-3 41. Tang WK, Chiu H, Woo J, Hjelm M, Hui E Telepsychiatry in psychogeriatric service: a pilot study. Int J Geriatr Psychiatry 2001;16(1):88-93 42. Ball C. Telemedicine and old age psychiatry, in Telepsychiatry and e-mental health. Edited by Wootton R, Yellowlees P, McLaren P. London, England, Royal Society of Medicine Press, 2003, pp 183-196 43. Kropf NP, Grigsby RK. Telemedicine for older adults. Home Health Care Serv Q 1999; 17(4):1-11 44. Wittson CL, Duton R: A new tool in psychiatric research. Ment Hosp 1956;7:11-14 45. Hassol A, Gaumer G, Grigsby J, Mintzer CL, Puskin DS, Brunswick M. Rural telemedicine: a national snapshot. Telemed J 1996;2(1):43-8 46. Lipson LR, Henderson TM. State initiatives to promote telemedicine. Telemedicine Journal 1996;2(2):109-21 47. Bratton RL, Cody C. Telemedicine applications in primary care: a geriatric patient pilot project. Mayo Clin Proc 2000;75(4):365-8 48. Chae YM, Heon Lee J, Hee Ho S, Ja Kim H, Hong Jun K, Uk Won J. Patient satisfaction with telemedicine in home health services for the elderly. Int J Med Inf 2001;61(2-3):167-73 49. Stroetmann KA, Erkert T. 'HausTeleDienst'--a CATV-based interactive video service for elderly people. Stud Health Technol Inform 1999;64:245-52 50. Gustke SS, Balch DC, West VI, Rogers LO. Patient satisfaction with telemedicine. Telemed J 2000;6:5-13 51. Mair F, Whitten P. Systematic review of studies of patient satisfaction with telemedicine. Bmj 2000;320(7248):1517-20 52. Hui E, Woo J, Hjelm M, Zhang YT, Tsui HT. Telemedicine: a pilot study in nursing home residents. Gerontology 2001;47(2):82-7 53. Nakamura K, Takano T, Akao C. The effectiveness of videophones in home healthcare for the elderly. Med Care 1999;37(2):117-25 54. Montani C, Billaud N, Couturier P, Fluchaire I, Lemaire R, Malterre C, Lauvernay N, Piquard JF, Frossard M, Franco A. 'Telepsychometry': a remote psychometry consultation in clinical gerontology: preliminary study. Telemedicine Journal 1996; 2(2):145-50 55. Ball C, Puffett A. The assessment of cognitive function in the elderly using videoconferencing. J Telemed Telecare 1998;4 Suppl 1:36-8 56. Montani C, Billaud N, Tyrrell J, Fluchaire I, Malterre C, Lauvernay N, Couturier P, Franco A. Psychological impact of a remote psychometric consultation with hospitalized elderly people. J Telemed Telecare 1997;3(3):140-5 57. Shores MM, Ryan-Dykes P, Williams RM, Mamerto B, Sadak T, Pascualy M, Felker BL, Zweigle M, Nichol P, Peskind ER. Identifying undiagnosed dementia in residential care veterans: comparing telemedicine to in-person clinical examination. Int J Geriatr Psychiatry 2004;19(2):101-8 58. Loh PK, Ramesh P, Maher S, Saligari J, Flicker L, Goldswain P. Can patients with dementia be assessed at a distance? The use of Telehealth and standardised assessments. Intern Med J 2004;34(5):239-42 _____________________________________________________________________